1. JENNIFER BASARAB-TUNG ABDOMINAL SURGERY ROTATION Communication and Conflict Resolution in the OR

2. Why Is This Needed? We as anesthesiologists sensed a need for improvement in mutual communication skills  Surgical chiefs agree this need is present Effective communication is one of the 6 core competencies that must be demonstrated for successful completion of residency Poor teamwork and communication are key factors responsible for medical errors  Poor communication identified as the root cause of 35% of anesthesia-related sentinel events

3. Can Communication Be Taught? Some might say “you can’t teach an old dog new tricks,” but… Students are interested in learning about this…  In a study that surveyed Iranian medical students, positive attitudes toward learning communication skills were more prevalent than negative attitudes  Interestingly, positive attitudes were more prevalent and negative attitudes less prevalent in female medical students and those in the basic science portion of their training  Indicates that we enter medical school knowing that communication is important, but it seems to be lost on us later in our training And specific interventions for physicians have been successful (see next slide)…

4. Teaching Communication Skills In a 2011 study, oncologists were randomly assigned to a brief palliative care-focused communication skills training course using patient actors  11-hour workshop in small groups followed by 30 minutes of individual coaching  Pre- and post-intervention assessments of skills  Intervention improved communication skills significantly and with moderate to large effect size  Both global communication skills and skills with respect to palliative care discussions were improved

5. Communication and Conflict Breakdowns in communication are one of the most frequent causes of conflict in health care  Unresolved conflict in turn creates an impediment to communication and undermines the teamwork that is necessary for good patient care The OR is at risk for conflict because:  There are many different professionals with overlapping and sometimes poorly delineated responsibilities  Two physicians sharing equal responsibility for patient  Complex, high-pressure work environment  Sleep deprivation and stress affect interactions  Ethical conflicts and conflicts of interest may emerge

6. Anesthesia-Related Sources of Conflict Postponement/cancellation of cases  How we communicate this to surgeons can potentially have a positive or negative effect on how they perceive it  Some information is usually lost in the interaction Changing anesthesiologist assignment just before the beginning of a case Double-coverage causing delays in induction and emergence

7. Conflict Resolution in General Five basic mechanisms of conflict resolution  Avoidance – unlikely to be useful in the OR because conflict is prevalent in this environment  Yielding – one side acquiesces to the other; appropriate when one party recognizes that they are in error  Collaboration – the preferred approach, which focuses on achieving goals together and is a “win-win” system  Compromise – both sides make trade-offs  Competition – conflict is seen as a zero-sum game that is won by one party and lost by the other

8. Conflict Resolution in the OR Conflict resolution in the OR requires participation at the institutional and individual levels Institutional:  Establish an institution-wide conflict management program  Build a culture that welcomes normative conflict resolution  Foster group cohesion

9. Conflict Resolution in the OR (continued) Personal:  Anticipate conflict and develop communication skills  Identify the precise source of the conflict  Establish personal rules of conduct  Emphasize shared standards and goals  Find a nonjudgmental starting point for discussion  Recognize shared frustrations with the system  Conduct any necessary confrontation in a private setting  Have a low threshold for intervention by a third party  Transfer patient care to an uninvolved colleague if conflict is irreconcilable

10. Conflict Resolution in the Stanford OR Per Dr. Cannon, the best way to resolve an ongoing conflict is to submit a SAFE report SAFE reports are read by Dr. Cannon, Dr. Brodsky, or Dr. Fanning Dr. Cannon can set up mediation-type meetings with individuals and between involved parties to help find a solution

11. Aggressive Behavior

12. Frustration-aggression hypothesis: aggression arises from the experience of being prevented from reaching an expected goal (frustration)  Modulated by social learning and perceived intention  Situational factors such as pain and hot temperatures make aggression more likely  Conversely, good communication skills can mitigate aggression In the context of health care, frustration comes in the form of feeling disrespected, not being listened to, and being treated unfairly  Or perceiving any of these, independent of actual presence

13. How to De-Escalate Aggression Stay calm and respectful Approach in a warm, friendly, open manner and avoid closed body language (crossed arms, standing too close) Speak softly and clearly in short sentences while avoiding condescension Maintain nonthreatening eye contact Use facial expressions or nodding to convey attentiveness & understanding Determine the right time to speak  Wait for the heightened emotion to recede before responding Avoid distracting activities such as writing or looking at the computer Show compassion and consideration Ask open-ended questions to get the other person's point of view Acknowledge frustration and the importance of the issue Give a clear message that you understand and want to help Explore solutions and provide choice whenever possible

14. Verbal and Nonverbal Communication Skills Many of the de-escalation techniques mentioned above are simply elements of good communication  Maintaining eye contact  Avoiding closed posture such as crossed arms  Speaking in calm, soft tones and avoiding “talking down”  Conveying attentiveness with facial expressions and gestures  Avoiding distractions  Avoiding interrupting the other person Practice these skills during any conversation, not only ones involving conflict and aggression

15. Psychology of Communication Basic Functions of Communication in an Acute Medical Care Setting  Build and maintain team structure  Coordinate team process and task execution  Exchange information  Facilitate relationships Four Aspects of a Message  Content: Information about facts, objects, and events  Self-revelation: Information about the sender as person  Relationship: Information about the relationship between sender and receiver  Appeal to Act: Many messages tell the receiver how he or she is supposed to act Helpful to keep in mind the functions and aspects of messages in order to make your messages more effective

16. Nonverbal and Paraverbal Communication Paraverbal communication  Tone, pitch, and pacing of our voices Nonverbal communication  Gesture, posture, facial expression, and eye contact These help the receiver understand the meaning of a message in its larger situational context  Compared to words, they are much more colored by attitudes and emotions and are less under conscious control  If verbal and nonverbal channels are incongruent, we will subconsciously place greater importance on the nonverbal and paraverbal cues. So it’s not always what we say that’s most important, but how we say it.

17. Dysfunctional Communication Patterns Unspecified receiver  “Could somebody…” or “we should…” Poor speech patterns  Speaking in a low voice or too hastily, mumbling, unfinished sentences, strong dialect, poor grammar Too much information  Rapid presentation of info, minimal pauses, long lists, run-on sentences Too little information  Abandoning explanations, not replying to questions, monosyllabic answers, periods of silence Passivity or aggressiveness  It is preferable to be assertive but not aggressive; e.g., use words to express any anger you feel in a civil manner. Poor listening  Interrupting, diverting, debating, quarreling, tuning out, reactive behavior (defiance, refusal, intentional failure, aggression, arrogance)

18. Good Communication in Critical Situations Communicate congruently (verbal, paraverbal, nonverbal) Be able to talk about communication failure and address it at the right time Speak unambiguously – be clear in what your message is and who you are addressing Close communication gap using readback/hearback (see next slide) Brief your team members so all are aware of the situation at hand Search actively for information Be assertive but not aggressive Listen actively:  Be patient and do not interrupt  Ask questions  Eye contact  Paraphrase and mirror (e.g. “So you’re saying we haven’t assessed for hyperkalemia and should check an ABG potassium now”)  Be supportive of the person you are talking with

19. Standardization of Communication Use standard terminology Ensure that messages are clearly heard and understood using callouts, readback, and hearback  Callout: a concise statement in a defined terminology  E.g. “I’m going to defibrillate now; please charge to 200”  Readback and hearback: aimed at verifying that both sender and receiver understood what has been said  E.g. assistant responds with “Charged to 200” (readback) and you confirm with “Ready to defibrillate – clear!” (hearback) Health care professionals tend to dismiss this procedure as unnecessary due to a lack of familiarity with it  However, standardization can help reduce misunderstanding in noisy and stressful situations

20. Teamwork The OR is a team environment that requires good communication and collaboration between team members Teamwork requires mutual respect and communication  Briefing, ongoing observation, and debriefing help create a good tone for team collaboration The field of healthcare has traditionally neglected the role of teamwork because:  Deep-seated cultural issues (individualistic culture)  Assumptions about the value of individual expertise  Strongly hierarchical power relationships A major problem is the lack of a shared understanding about necessity and forms of teamwork

21. Six components of team communication: Situational awareness – where have we come from, where are we now, and where are we going? Problem identification – requires all team members to be comfortable with speaking up voluntarily and without hesitation Decision making – requires adequate diagnosis of the problem, generation of solutions, and assessment of chances of adverse outcomes Workload distribution – delegation of assigned tasks so no single individual is overloaded Time management – linked to situational awareness Conflict resolution – includes listening well, acknowledging feelings, and building respect

22. Team Players A successful team player can:  Listen and participate actively  Ask the right questions  Hold an opinion but change his/her point of view if necessary  Assess and value the qualities of other team members  Similarly, assess what you can do best and where others have more experience  Keep to an agreement and identify with a task  Be self-critical  Solve conflicts in a constructive way

23. Teams Under Pressure In stressful situations, team members often behave in maladaptive ways:  Information gathering is abandoned early  No reflection on the problem  No discussion about goals  No search for alternative solutions  Group pressure, suppression of disagreement  Risk shift  If several physicians are in charge of an emergency without having a team leader, nobody perceives themselves as accountable for the outcome, so the tendency for risky decisions increases  Diffusion of responsibility  Individuals fail to take action because they believe another individual will act or have already done so)  Lack of coordination Be aware of these destructive patterns and fight them when you see them occurring

24. Summary Communication is a key aspect of acute medical care in an environment such as the OR Good communication skills can be taught Basic verbal and nonverbal communication skills can be used to resolve conflicts and de-escalate aggressive behavior Nonverbal and paraverbal communication can be more important than the verbal message Learning the psychology of communication helps us understand dysfunctional communication patterns and correct them Standardizing communication via callout, readback, and hearback help reduce misunderstandings Teamwork is essential to acute medical care Team members can behave in dysfunctional ways when stressed, so it is important to understand and implement the elements of good team communication

25. And Finally… Don’t overestimate your abilities! Just as calling for help is useful in a medical crisis, turning to others can assist in conflict resolution.

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